amyotrophy (otherwise known as proximal motor neuropathy) typically occurs in older patients with type 2 diabetes and can present with severe neuropathic pain affecting one or both lower extremities, particularly in the thigh region. The pain might be extremely troublesome with marked nocturnal exacerbation and sleep disruption. A history, together with clinical features of weakness and wasting in the proximal thigh muscles, is usually suggestive of this condition although the exclusion of malignant disease and other treatable neuropathies, such as chronic inflammatory demyelinating neuropathy (CIDP) (Chapters 1 and 13) is recommended. One of the principal features of the truncal neuropathies is that of pain usually described as being of a burning or aching quality, and frequently accompanied by lancinating stabbing discomfort with cutaneous hyperaesthesiae and nocturnal exacerbation.

Generalized Symmetrical Polyneuropathy

Acute painful sensory neuropathy has been described as a separate clinical entity (9), and appears to be a distinctive variant of symmetrical polyneuropathy that warrants a separate discussion. Although many of the symptoms of acute and chronic sensorimotor neuropathy are similar if not identical, there are clear differences in the mode of onset, accompanying signs, symptom severity, and prognosis that are summarized in Table 2. The outstanding complaint in acute sensory neuropathy is one of severe neuropathic pain with marked sleep disturbance. Weight loss, depression, and frequently in the male, erectile dysfunction, are common accompanying features, although the clinical exam of the lower limbs is often unremarkable with preserved reflexes and few sensory signs. This acute neuropathy is associated with poor glycemic control and may follow an episode of ketoacidosis and has been associated with weight loss and eating disorders (10).

Chronic Sensorimotor Neuropathy

This is by far, the most common manifestation of all the diabetic neuropathies and as noted elsewhere, might be present at the diagnosis of type 2 diabetes. In many ways

Table 3

Characteristics of Neuropathic Pain Characteristics of Neuropathic Pain


Nociceptive or nerve-trunk

Unfamiliar Burning, "on fire" Throbbing, prickling

Familiar to patient

Aching, tender, like toothache


Electrical shock-like Knife-like

Allodynia (nonnoxious stimulus giving rise to pain) Hyperesthesia (increased sensitivity)

chronic sensorimotor neuropathy manifests a spectrum of symptomatic involvement: at one end of the spectrum there are patients with persistent troublesome neuropathic symptoms and evidence of sensory and motor dysfunction on examination of the lower limbs, whereas at the other end, the patient might be completely asymptomatic and still have a significant neuropathic deficit on examination. Intermediate between these two extremes are patients with moderate, but intermittent symptomatology (sometimes painless, but may be with "negative" symptoms, such as numbness, feet feel dead, and so on) and neurological abnormalities on examination of the feet. Even more confusing for the patient is the "painful-painless" foot. In these patients, there might be spontaneous painful symptomatology, but on examination there is marked loss of pain vibration, and other sensory modalities.

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